Failure to Provide Appropriate Mental Health Treatment and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with mental disorders or psychosocial adjustment difficulties, as evidenced by multiple incidents involving three residents. One resident with a history of schizoaffective disorder, bipolar disorder with severe psychotic features, and paraplegia exhibited escalating behaviors, including frequent calls to 911, verbal aggression, yelling, and a suicide attempt. Despite documented behaviors and repeated hospitalizations, there were no behavior monitoring or intervention orders in place, and staff were unaware of the resident's extensive history of suicide attempts and aggressive behaviors. The care plan did not adequately address the resident's risk for self-harm or aggression, and the interdisciplinary team failed to review or act upon hospital discharge records detailing the resident's psychiatric history and recent suicide attempt. Another resident with schizophrenia and anxiety disorder demonstrated severely impaired cognition and exhibited aggressive behaviors, including yelling, cursing, throwing objects, and making suicide threats. The care plan did not address suicidal behavior or suicide threats, and there was no evidence of behavior monitoring or interventions specific to these risks. Staff documented multiple incidents of physical and verbal aggression, as well as statements of intent to self-harm, but interventions were limited to medication administration and attempts at verbal redirection, which were often unsuccessful. The facility did not implement comprehensive behavioral interventions or monitoring to address the resident's escalating behaviors and suicide threats. A third resident displayed continuous behaviors such as pacing, banging on doors, and intrusive interactions with other residents and staff, but the facility failed to provide treatment and services to correct these behaviors. The lack of appropriate interventions and monitoring for residents with significant mental health and behavioral needs resulted in repeated incidents requiring emergency intervention, including police involvement and physical restraint. The facility's failure to assess, monitor, and address the residents' mental and psychosocial needs placed residents at risk for harm and did not support their highest practicable mental and psychosocial well-being.